Biodata Klien Anak
Client Bio Form
Layanan yang Dibutuhkan Saat Ini
Required Service
Klien
Cornerstone
JCGC
Apa layanan yang Anda perlukan? [What type of service do you require?]
*
Please Select
Konseling/Konsultasi [counseling/consultation]
Child Comprehensive Evaluation
Child Brief Evaluation
Tes IQ [IQ Profile]
Kesiapan Belajar [School/Academic Readiness]
Tes Minat Bakat [Career Pathway & Exploration]
Tes Keberbakatan [Giftedness Test/Screening]
Terapi Okupasi [Occupational Therapy]
Terapi Wicara [Speech Therapy]
Terapi Bermain [Play Therapy]
Terapi Neurofeedback [Neurofeedback Therapy]
Terapi Seni [Art Therapy]
Terapi Musik [Music Therapy]
Terapi Remedial [Remedial Therapy]
Gifted Assessment
Body Support Program
Psikolog yang akan menangani [Assigned Psychologist/Counselor]
*
Please Select
Allessandra Theresia, M.Psi., Psikolog
Ayutias Anggraini, M.Psi., Psikolog
Christella Ruslan, M.Psi., Psikolog
Christina Tedja, M.Psi., Psikolog
Clara Gia Shinta, S.Pd., M.A., Psikolog
Eunike Mutiara, Ph.D., Psikolog
Fransisca Febriana Sidjaja, Ph.D, Psikolog
Frida Sisca, M.Psi., Psikolog
Giavanny Panatra, M.Psi., Psikolog
Grace Indrawati, M.Psi., Psikolog
Gracia Stephanie, M.Psi., Psikolog
Helsa, M.Psi., Psikolog
Karel Karsten Himawan, Ph.D, Psikolog
Krishervina R. Lidiawati, M.Psi., Psikolog
Mentari Puteri, M.M., M.Psi., Psikolog
Monalysa Ginting, M.Psi., Psikolog
Naomi Kristiana., M. Psi., Psikolog
Sandra Handayani Sutanto, M.Psi., Psikolog
Susana Ang, PGCert.PT
Vickie Januar, M.Psi., Psikolog
Yuliana Anggreany, M.Psi., Psikolog
Justine Elisse, M. Psi., Psikolog
Vinesia Febrianti, M.psi., Psikolog
Belum ada referensi [no reference yet]
Cornerstone Center
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Data Orang Tua
Parent's Information
Nama Ayah [Father's Name]
*
First Name
Last Name
Email [Email]
*
example@example.com
No. HP [Phone Number]
*
-
Area Code [+62]
Phone Number
Alamat [Address]
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agama [Religious Preference]
*
Please Select
Islam [Islam]
Protestan [Protestant]
Katolik [Catholic]
Buddha [Buddhaism]
Hindu [Hinduism]
Konghucu [Confucious]
Atheist [Atheism]
Memilih untuk tidak menjawab [Prefer not to say]
Kewarganegaraan [Citizenship]
*
Please Select
Indonesia [WNI]
Asing [Foreign/WNA]
Pekerjaan [Occupation]
*
Agama [Religious Affiliation]
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Nama Ibu [Mother's Name]
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First Name
Last Name
Jenis Kelamin [Sex]
*
Please Select
Laki - Laki [Male]
Perempuan [Female]
Email [Email]
*
example@example.com
No. HP [Phone Number]
*
-
Area Code [+62]
Phone Number
Alamat [Address]
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agama [Religious Preference]
*
Please Select
Islam [Islam]
Protestan [Protestant]
Katolik [Catholic]
Buddha [Buddhaism]
Hindu [Hinduism]
Konghucu [Confucious]
Atheist [Atheism]
Memilih untuk tidak menjawab [Prefer not to say]
Kewarganegaraan [Citizenship]
*
Please Select
Indonesia [WNI]
Asing [Foreign/WNA]
Pekerjaan [Occupation]
*
Status Pernikahan [Marital Status]
*
Please Select
Menikah [Married]
Bercerai [Divorce]
Memilih untuk tidak menjawab [Prefer not to say]
Lainnya [Others]
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Pendidikan Anak Saat Ini
Current Child Education
Nama Sekolah [School Name]
*
Jika belum bersekolah, silahkan tulis "belum bersekolah" [If haven't go to school, please write "not school yet"]
Kelas [Grade]
*
Jika belum bersekolah, silahkan tulis "belum bersekolah" [If haven't go to school, please write "not school yet"]
Kurikulum [Curriculum]
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Inklusi
Reguler
IB
Cambridge
National Plus
Gifted
Other
Apakah ada masalah atau keluhan dari sekolah? [Are there any problems reported by the school?]
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Riwayat Terapi
Therapy Record
Jenis Terapi/intervensi yang pernah atau sedang dilakukan dan sudah berapa lama dilakukan [Current or past therapies/interventions and how long it has been done]
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Diagnosa yang pernah diberikan [Diagnosis previously given by a professional]
isi dengan keterangan nama dokter/psikolog/ahli lain yang memberi diagnosa, diagnosa, dan usia anak saat diberikan diagnosa [fill out with name of doctor/psychologist/other professional that gave the diagnosis, diagnosis, and child's age when diagnosis was given]
Jika ada, Unggah Rekam Medis/Laporan Terapi [If any, please upload medical record/therapy report]
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Keluhan / Masalah
Issue Identification
Mohon ceritakan secara singkat keluhan Anda [Reasons for referral]
*
Usaha yang telah dilakukan untuk mengatasi keluhan [Actions taken to resolve the problem/issue]
*
Isi dengan (-) jika belum pernah diatasi sebelumnya (please fill with "-" if you have done nothing before]
Apa harapan Anda setelah melakukan proses konseling/terapi di BFL? [What are your expectations after completing the counseling/therapy process at BFL?]
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Identitas Anak
Child's Personal Information
Nama [Full Name]
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First Name
Last Name
Nama Panggilan [Nickname]
*
Tempat Lahir [Place of Birth]
*
Tanggal Lahir [Date of Birth]
*
/
Day
/
Month
Year
Date
Usia Anak Saat Ini [Current Age]
*
Jenis Kelamin [Sex]
*
Please Select
Laki-laki [Male]
Perempuan [Female]
Agama [Religious Preference]
*
Please Select
Islam [Islam]
Protestan [Protestant]
Katolik [Catholic]
Buddha [Buddhaism]
Hindu [Hinduism]
Konghucu [Confucious]
Atheist [Atheism]
Memilih untuk tidak menjawab [Prefer not to say]
Anak ke / dari total bersaudara [birth order]
*
Misal: anak ke 2 dari 3 bersaudara, maka tulis: 2 / 3 [Example: being the 2nd of 3 total siblings, please write: 2 / 3]
Jika sudah bersekolah, tuliskan nama sekolah saat ini [If your child is already in school, please provide the name of the school]
*
Jika belum bersekolah, silahkan tulis "belum bersekolah" [If haven't go to school, please write "not school yet"]
Silakan tuliskan kelas/jenjang pendidikan saat ini [Please specify the current class or grade]
*
Jika belum bersekolah, silahkan tulis "belum bersekolah" [If haven't go to school, please write "not school yet"]
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Riwayat Kehamilan Ibu
Maternal Pregnancy History
Usia ibu saat hamil [Mother's age at the time of pregnancy]
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Apakah Ibu pernah mengalami keguguran? [Has the mother ever experienced a miscarriage?]
Ya [Yes]
Tidak [No]
Memilih untuk tidak menjawab [Prefer not to say]
Apakah Ibu pernah mengalami stress psikologis selama kehamilan? [Did the mother experience psychological stress during pregnancy]
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Ya [Yes]
Tidak [No]
Memilih untuk tidak menjawab [Prefer not to say]
Jelaskan bentuk stres psikologis yang dialami oleh Ibu [Please describe the psychological stress experienced during pregnancy]
Apakah Ibu pernah mengalami sakit hingga perlu perawatan medis yang serius? [Has the mother ever experienced an illness that required serious medical treatment?]
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Ya [Yes]
Tidak [No]
Jelaskan mengenai sakit yang diderita [Please describe any illnesses the mother has experienced]
Apakah Ibu mengkonsumsi obat-obatan di luar resep dokter? [Does the mother take any medication that is not prescribed by a doctor?]
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Ya [Yes]
Tidak [No]
Memilih untuk tidak menjawab [Prefer not to say]
Jika ada, mohon sebutkan nama obat yang dikonsumsi [Please list the names of the medications taken.]
Apakah Ibu pernah melakukan pemeriksaan TORCH? [Has the mother ever had a TORCH test?]
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Ya [Yes]
Tidak [No]
Jika ada, bagaimana hasil pemeriksaan TORCH? [If so, what were the results of the TORCH test?
TORCH : Toxoplasma, Other infection (Chlamydia, HIV, Hepatitis B, dan lain-lain), Rubella, Cytomegalovirus dan Herpes
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Riwayat Kelahiran Anak
Birth History
Berapa usia kehamilan Ibu saat bersalin? [Gestational Age]
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Isi dengan satuan minggu, contoh tulis 40 jika usia kehamilan 40 minggu [Weeks]
Apakah ada komplikasi/kesulitan selama proses persalinan? [Were there any complications/difficulties during the labor process?]
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Ya [Yes]
Tidak [No]
Jika ya, jelaskan komplikasi/kesulitan yang terjadi [Describe the complications/difficulties]
Bagaimana proses persalinan? [The labor's process]
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Normal (pervaginam)
C-Section
Memilih untuk tidak menjawab [Prefer Not To say]
Berat badan lahir anak [Child’s birth weight]
*
Jika tidak ingat dengan jelas, silahkan tuliskan dengan angka yang paling mendekati [If you don't remember clearly, please write the closest number]
Panjang badan lahir anak [Child’s birth height]
*
Jika tidak ingat dengan jelas, silahkan tuliskan dengan angka yang paling mendekati [If you don't remember clearly, please write the closest number]
Lingkar kepala saat lahir [Child’s head circumference at birth]
*
Jika tidak ingat dengan jelas, silahkan tuliskan dengan angka yang paling mendekati [If you don't remember clearly, please write the closest number]
Apakah bayi langsung menangis ketika lahir [Did the baby cry immediately after birth?]
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Ya [Yes]
Tidak [No]
Memilih untuk tidak menjawab [Prefer not to say]
Apakah ada komplikasi saat lahir? [Were there any complications during the birth?]
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Sesak nafas [Asphyxiate]
Pucat [Pale]
Kadar bilirubin tinggi [High bilirubin levels]
Kejang [Seizure]
Biru [Blue]
Pendarahan [Hemorrhage]
Infeksi serius [Serious infection]
Tidak ada komplikasi [No Complication]
Other
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Status Kesehatan Anak
Child Health
Apakah Anak pernah mengalami penyakit serius sehingga membutuhkan bantuan medis? [Has the child ever had a serious illness that required medical treatment?]
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Ya [Yes]
Tidak [No]
Other
Jika ya, jelaskan riwayat penyakit dan berapa lama memerlukan perawatan? [If yes, please describe the history of the illness and the duration of the treatment required]
Apakah Anak pernah mengalami benturan keras di kepala? [Has your child ever experienced a significant bump to the head?]
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Ya [Yes]
Tidak [No]
Apakah Anak pernah atau sedang melakukan pengobatan jangka panjang? [Has the child ever taken or is currently taking long-term medication?]
*
Ya [Yes]
Tidak [No]
Other
Jika ya, jelaskan riwayat penyakit dan pengobatan yang dilakukan [If yes, please explain the history of the illness and the treatment used]
Apakah Anak memiliki riwayat alergi? [Does the child have a history of allergies?]
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Ya [Yes]
Tidak [No]
Jika ya, jelaskan riwayat alerginya [If yes, please describe the history of the allergies]
Apakah Anak pernah melakukan tes pendengaran? [Has your child ever had a hearing test?]
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Ya [Yes]
Tidak [No]
Jika ya, jelaskan hasil tes pendengaran tersebut [If yes, please describe the results of the hearing test]
Apakah Anak pernah melakukan tes mata/penglihatan? [Has your child ever had an eye/vision test?]
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Ya [Yes]
Tidak [No]
Jika ya, jelaskan hasil tes mata/penglihatan tersebut [If yes, please describe the results of the eye/vision test]
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Riwayat Perkembangan Anak
Child Development History
Perkembangan Motorik Kasar (usia anak ketika kemampuan tercapai) [Gross Motor Skill Development (the age at which the child achieved each ability)] | Jika tidak ingat dengan jelas, silahkan isi dengan angka yang dirasa paling mendekati [If you don't remember exactly, please provide the closest estimate]
*
Jelaskan dengan singkat pola makan anak dari usia 0-2 tahun! [Briefly describe the eating habits of children from 0 to 2 years old!]
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Jelaskan dengan singkat pola tidur anak dari usia 0-2 tahun! [Briefly describe the sleep habit of children from 0-2 years old!]
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Apakah anak sudah terpapar gadget/TV (screen time)? [Has the child been exposed to gadgets or TV?
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Ya [Yes]
Tidak [No]
Jika ya, sebutkan sejak usia berapa anak terpapar layar gadget/TV dan berapa lama durasi dalam sehari? [If so, please specify from what age the child was exposed to gadgets or TV screens and how long the exposure lasts each day.]
*
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Kondisi Sensori Anak
Child Sensory Condition
Anak saya terlalu sensitif terhadap stimulasi, bereaksi secara berlebihan, atau tidak suka terhadap sentuhan, kebisingan, bau, dan sebagainya. [My child is overly sensitive to stimulation, tends to overreact, or dislikes touch, noise, smells, and similar stimuli.]
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Ya [Yes]
Tidak [No]
Anak saya mudah terdistraksi di dalam kelas, seringkali pergi dari tempat duduknya dengan gelisah. [My child gets easily distracted in class and often leaves their seat restlessly.]
*
Ya [Yes]
Tidak [No]
Anak saya mudah kewalahan di tempat bermain, saat jam istirahat, atau di dalam kelas. [My child easily gets overwhelmed at the playground, during break time, or in the classroom.]
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Ya [Yes]
Tidak [No]
Anak saya lambat dalam melakukan tugas-tugasnya. [My child needs more time in completing tasks.]
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Ya [Yes]
Tidak [No]
Anak saya memiliki kesulitan dalam menunjukkan atau menghindari tugas-tugas motorik halus seperti menulis. [My child has difficulty in demonstrating or avoiding fine motor tasks, such as writing.]
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Ya [Yes]
Tidak [No]
Anak saya tampak ceroboh/canggung dan sering tersandung serta membungkuk di kursi. [My child seems clumsy/awkward and often trips and slouches in the chair.]
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Ya [Yes]
Tidak [No]
Anak saya menyukai permainan yang kasar, seperti permainan berkelahi/bergulat. [My child enjoys rough play, like fighting or wrestling games.]
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Ya [Yes]
Tidak [No]
Anak saya lambat dalam mempelajari aktivitas-aktivitas yang baru. [My child takes time to learn new activities.]
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Ya [Yes]
Tidak [No]
Anak saya melakukan gerakan berulang yang sama secara terus menerus. [My child makes constant or repetitive movements.]
*
Ya [Yes]
Tidak [No]
Anak saya memiliki kesulitan dalam mempelajari kegiatan motorik yang baru dan lebih suka beraktivitas yang dilakukan secara terus-menerus/aktivitas yang sudah pernah dilakukan sebelumnya secara terus-menerus. [My child has difficulty learning new motor activities and prefers to engage in repetitive activities or those that have been done before.]
*
Ya [Yes]
Tidak [No]
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Perkembangan Bahasa dan Bicara
Speech and Language Development
Bahasa sehari-hari yang digunakan [Language spoken by your child]
*
Apakah anak anda kesulitan mengikuti instruksi verbal? [Does your child have difficulty following verbal instructions?]
*
Tidak [No]
Ya [Yes]
Jika Ya, Jelaskan [If yes, please describe]
Apakah instruksi verbal perlu diulang? [Do the instructions need to be repeated?]
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Tidak [No]
Yes [Yes]
Jika Ya, Jelaskan [If yes, please describe]
Bagaimana cara anak anda berkomunikasi [How does your child communicate?]
*
Menangis/berteriak [crying/screaming]
Isyarat/menunjuk [Gestures/Pointing]
Suara dan isyarat [Sound and gestures]
Satu kata [one word]
Kalimat pendek [Short Sentences]
Kalimat Panjang [Long sentences]
Other
Mohon jelaskan [please describe]
Apakah ada kesalahan tata bahasa dalam penggunaan kalimat? e.g: kalimat terbalik-balik atau tidak lengkap [Are there grammatical errors in the sentences used? e.g: reversed sentences or incomplete sentences]
Tidak [No]
Ya [Yes]
Jika Ya, Jelaskan [If yes, please describe]
Apakah anak anda kesulitan dalam mengekspresikan idenya [Does your child have difficulty expressing their ideas?]
*
Tidak [No]
Ya [Yes]
Jika Ya, Jelaskan [If yes, please describe]
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Partisipasi Sosial
Social Participation
Bagaimana kesan anak sehari-sehari? [What is the impression of the child in daily life?]
*
Menarik diri [Avoidant]
Diam/pasif [Passive]
Overaktif [Hyperactive]
Normal [Normal]
Apakah ada dari perilaku berikut ini yang muncul pada anak? [Are any of the following behaviors observed in the child?]
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Impulsif [Impulsive]
Agresif [Aggressive]
Tidak percaya diri [Uncofident]
Kaku [Rigid]
Cemas [Anxious]
Mudah marah [Easy to get angry]
Cari perhatian [Attention seeker]
Malu-malu [Shy]
Other
Apakah anak menunjukkan kesulitan bermain dalam kelompok? [Does the child have difficulty playing in groups?]
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Ya [Yes]
Tidak [No]
Jelaskan kesulitan yang ditunjukkan [Please describe the difficulty observed]
Siapa yang mengasuh anak dalam kesehariannya? [Who takes care of the child's daily care?]
*
Orang Tua [Parent]
Kakek / Nenek [Grandparent]
Om / Tante [Uncle/Aunty]
Nanny / ART [Nanny / Baby Sitter]
Other
Adakah informasi penting lainnya berkaitan dengan kondisi anak yang Anda rasa penting untuk diketahui psikolog? [Is there any additional important information about the child's condition that psychologists should be aware of?]
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Foto Anak
Child Photo
Unggah foto anak di sini [Upload your kids self photo here]
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Lembar Persetujuan [Informed Consent]
Mohon pelajari syarat dan ketentuan untuk layanan kami dan berikan persetujuan di bawah. [Please review the terms and conditions for our service and indicate your agreement below].
Silakan tanda tangan di sini jika Anda telah setuju dengan semua jawaban Anda [Please sign here if you agree with all of the responses provided above]
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